Jeremy Hunt’s ridiculous “name and shame” proposal threatens the entire NHS. But he’s right.

 

Shame game
Shame game

 

Jeremy Hunt, the UK’s Health Secretary, wants to “name and shame” GPs whose cancer referral rates are lower than their peers.

It’s a cack-handed, polemic attack on the most stretched professionals in the NHS. It jeopardises any rational assessment of whether or not a patient is likely to have cancer. It goes against everything we know about successfully learning from mistakes, engaging staff and building productive teams in healthcare.

Facing the threat of being labelled “cancer cretins”, GPs will generate a tidal wave of referrals for the worried well, driving up waiting times for the patients who actually need a rapid assessment.

The boss, until the next boss.
The boss, until the next boss.

It’ll cause mayhem, worsen cancer care, and destabilise entire local healthcare economies.

And yet – he’s right. Almost.

Hunt’s proposal suggests that patient safety is fundamentally about making the right diagnosis. Strange as it sounds, that hadn’t been a focus in patient safety research until recently (see this 2012 JAMA viewpoint). Patient safety work had traditionally focused on stopping active harms – surgeons chopping out the wrong kidney, or ward nurses inserting a feeding tube into the lungs rather than the stomach. This is important stuff – you can’t put right those mistakes. Organisations are mostly judged on how they measure, monitor and prevent these “never events”.

What we’re not judged on is whether we’re actually getting right the most fundamental part of medicine, making the right diagnosis. Hospital doctors rarely find out when they’ve made a diagnostic error – by that point, the patient’s usually on another ward, being looked after by another team who spotted the mistake. There’s no learning, either for the individuals involved or the organisation they work for. And patients suffer: ‘unremarkable’ missed opportunities to provide the right care make up the bulk of patient harm.

For the first time in the UK, Hunt’s outburst means that diagnostic accuracy  will be prioritised as a key component of patient safety. GPs, and then hospitals, will have to invest in making the right diagnosis – in the same way as they’ve had to invest in systems to reduce feeding tube complications, wrong site surgery or MRSA bloodstream infections.

The published diagnosis numbers may not be meaningful. They’ll be too prone to bias and misinterpretation (good healthcare systems make more diagnoses in the end, and get penalised for it – see here). But, like discussions about hospital mortality, simply opening the conversation about diagnosis should prompt meaningful reflection and improvement – even if the figures don’t reflect it.

In launching his latest attack on the quality of UK general practice, Jeremy Hunt may inadvertently have made a great leap forward for NHS patient safety.

The irony, of course, is that he didn’t mean it, GPs don’t want it, and patients will struggle to see the benefit.

The Presidential Royale With Cheese: Not Your Ordinary Medical

Presidential is a superlative word. It slides gracefully past the hiccups of the individual incumbent – Clinton’s cigar, Nixon’s break-in, de Gaulle’s personality – to conjure up images of statesmen, leadership and excellence.

Excellence is really the issue. When you get something called “The Presidential”, and priced to match, you expect the best.

The Presidential Suite. The Presidential Limousine. The Presidential Banquet. And now… The Presidential Check-Up.

Some countries have a grand tradition of loudly announcing the robust health of their leader, the USA being one of them. This reassures the populace – at least 50% of whom will despise him (or her), of course – that at least he won’t drop dead any time soon, so they’re free to carry on hating without any guilt.

Being the President, you don’t just have a quick chat with your doctor. The leader of the free world gets the Full Monty, the Royale with Cheese, the gourmet tasting menu of the panoply of tests medicine can offer.

Sensible precautions, surely, when your finger’s on the nuclear trigger. Or are they?

The Presidential is Killing the President

Something’s been wrong with the Presidential Medical for a long time. In 1995, Bill Clinton’s “routine” check-up involved a four-hour session with a general medical specialist, an otorhinolaryngologist, an allergist, a sports-medicine specialist, a dermatologist and a nutritionist. He’d seen a similar team just a year earlier. Barack Obama’s next thorough evaluation is coming up soon.

Correspondents to the New England Journal of Medicine – to which the White House does not subscribe – argued whether this was appropriate. Should there really be a dual approach for patricians and plebeians? Perhaps the President’s unique set of powers and responsibilities do alter the balance of risk and benefit inherent in every medical investigation.

As the rebuttal points out, the same logic could be applied to any employer, any professional with statutory responsibilities, even any parent. That’s why guidelines on screening exist – because we’re all unique, we’re all individual, and we all need guidance to protect us from unnecessary investigations.

The insinuation that indiscriminate testing is ‘better’ is a pervasive one. It suggests, by extension, that the rest of us are getting a poorer standard of care, when the reverse may be true. We may be killing the President – and anyone else paying through the nose for an unwarranted check-up – through this ‘kindness’.

Examine this

It’s not just that a battery of unnecessary tests may not make any difference to your health. They may actually expose you to harm. In 2013, George Bush underwent an invasive procedure – shown not to reduce his risk of a heart attack or dying – following on from a Presidential Royale with Cheese he didn’t need. He subjected himself to real risks, on the basis of a test he’d never needed to have in the first place. Obama underwent a colonoscopy, consenting to the possibilities of bleeding and intestinal perforation.

These Presidents did fine. But are we all so lucky? This piece in the New York Times summarised some of the dangers of accumulated ‘routine’ CT scans, which may contribute to 5% of the cancers we see in the future. A new campaign in the USA, Choosing Wisely, opens the conversation about tests that may harm rather than heal. It might help keep medicine safe for the masses, and for our political masters.

I want my political leaders spending time at their desks, not in a doctor’s clinic. If there are votes in proving your fitness, go for a run. The beneficial Presidential Check-Up is a myth: the Commander-in-Chief gets a worse deal than the rest of us.

Who’s really in charge? Definitely not the patient – and maybe not the doctor.

Like many men in their 30s, I’ve relinquished any authority in my personal life.

My wife and I have a tacit understanding that, for the most part, her decisions are better than mine. Rather than discuss our individual opinions, it’s much more efficient for me to simply agree with her.

The end result is the same, and there’s a chance for me to watch the football highlights in the time we would have spent making me come round to her way of thinking.

This unspoken agreement is like the Treaty of Versailles – a grudging settlement born of a long war of attrition, good enough to see us through a few wild decades before the resentment builds up too much.

Like all carefully-negotiated compromises, though, ours is entirely at the mercy of unpredictable third parties.

In our case, the proverbial and actual stinkbomb at the dinner party is our daughter, a toddler of implacable willpower. It’s (usually) a benign dictatorship – but she’s the real power behind the throne now, and both her parents know it.

It does make me wonder though – in medicine, who signed up to the peace treaty? Who’s leading the team? And who’s really in charge? The answers to these last two questions may not be the same.

You might think, as we move to a more patient-centred, less paternalistic style of healthcare that it’s obvious. “No decision about me, without me” – surely patients are leading us now, setting the parameters within which their subservient medical whipping-boys should toil?

This blog post on KevinMD.com argues otherwise, and it makes some strong points. Perhaps patients should be considered part of the healthcare team – using patient-reported outcome measures, for example, makes sure we’re really prioritising the results that patients care about. But do they captain the team? They don’t have the technical training or the expertise to coordinate a group of multidisciplinary professionals delivering complex care. And why should they?

If we “promote” patients to the head of the team, we’re abdicating our own responsibility for the care they receive. Even more importantly, we do them no favours by pretending they’ve got power if they don’t – it trivialises the role, and patronises them.

But if we agree that doctors still lead the healthcare team (at least for the moment), does that mean that we’re actually in charge?

Not necessarily. There’s usually someone in the background pulling the strings – be it a spouse, the head of your department, or something more malevolent. Chuck Denham, one of the heads of the patient safety movement in the USA, is facing allegations that he was paid $11.6 million to promote the choice of particular safety products in healthcare. The company paying the “kickbacks”, CareFusion, agreed to settle a lawsuit with the US Department of Justice for $40 million.

This might be an extreme example – there are normally strict rules on disclosing competing interests when you take on a role, which Denham avoided. Even without such blatant promotion of excess over evidence, we’re all susceptible to some outside pressures – workload, time, frustration, competing priorities and limited resources.

Most doctors will recognise that our medical decisions are influenced by a whole host of these extraneous factors, not necessarily happily connected to the patient in front of us. We should be happy to share the authority of our position – our colleagues, and our patients, make vital contributions that keep our decisions honest and right.

But the responsibility of our role demands that we remain accountable for those decisions. At the very least, our patients deserve that we reflect on why we make the decisions we do. We’re very rarely in sole charge of our teams, or our thought processes.

That’s what my wife says, anyway.

Sex-mad seniors: why the NHS is sending mixed signals

I’m quite looking forward to getting old.

Apparently it’s not all staring at the walls, waiting for distant relatives to visit, and a poor urine stream.

Old age just got sexy. Sort of.

According to the New York Times, 2.2 million elderly Americans each year need screening for sexually transmitted diseases (STDs). These septuagenarian sexual go-getters are getting chlamydia and syphilis, just like their grandchildren.

I don’t know how these pensioners are getting so frisky.  They’re playing erotic Twister, for crying out loud, at an age when I thought you needed physiotherapy just to keep your bowel movements regular.

Twister

It’s no surprise, though, that as our perceptions of health and age change, so does the way we tolerate illness. If you can live life in the sexual fast lane well into your 80’s, there’s no time for man flu. People flock to Emergency departments with trivial problems, impatient to get rid of the symptoms that simply need time to resolve.

This is bad for doctors. We’re not actually that comfortable delivering the phrase “just give it a few days”. It’s hard to muster the required gravitas.

It’s also bad for really sick patients, who can’t get through the hordes of sniffling impostors to see the doctor they need to.

Kiss

Recognising the only sensible way to deal with a critical public health crisis, the NHS faced the problem head on: we released a new video on YouTube. Take that, serious debate.

The paradox, of course, is that patients simultaneously ignore potentially serious symptoms for months – the cough that doesn’t go away, the insidious change in bowel habit, spots of blood in the urine.

Hence the inevitable, contradictory, Go See Your Doctor Now What Are You Waiting For You Irresponsible Cretin campaign:

Get well soon

It’s no wonder people are confused. The mixed signals we’re sending out wouldn’t do a lady’s reputation any good, at any age. And they’re not the work of a credible health organisation.

No Love Lost: The Rise and Fall of The Locum

The French and the British take very different approaches to affairs.

The recent revelations about François Hollande’s late-night escapades have destroyed his credibility.

Not because of any perceived loss of political knowhow, mind you. The French were simply outraged that Hollande, rather than crashing his Ferrari on the Champs Elysee like one of his predecessors, travelled to his late night liaisons on the back of a scooter.

To the French, it’s a question of style.

We British have a bigger problem. Our troubles also lie, typically, with foreign men who have complicated private lives: locum doctors. But when it comes to our old flames, we just don’t know how to let go.

Our dependence on locum doctors used to be a quaint joke. Permanent positions arose throughout the year, so there was a constant stream of junior doctors looking for temporary work.

“Getting a locum in” to fill a gap in the rota was as straightforward as pulling at a singles night. You might not end up with someone who looked good in the cold harsh light of the next morning. But they’d get you through the night (shift).

The system changed. Virtually all permanent posts are now made available at the same point in the year, and European working hours regulations demand adequate rest between shifts. Competition is fierce. It’s much more difficult to find anyone, let alone anyone with a decent CV, to help man a desperately-understaffed A&E department.

A worsening shortage of applicants for full-time positions in A&E exacerbates the crisis. Like the ghosts of past romances putting off future partners, multiple temporary staff do nothing to make a permanent A&E job more attractive.

So, despising themselves for being unable to resist temptation, hospital managers make that same ‘booty call’ to the locum: “Are you awake? We miss you. We need you.”

It’ll be hard to shake ourselves out of this spiral. Sadly, the traditional remedies – a diet, more exercise, less booze and no more late night texting – are unlikely to help.

Let’s not be too hard on the locums themselves, though. To paraphrase the classic breakup line: It’s Not Them, It’s Us.

Opening the wrong door: Futile care for those who can’t benefit

I know how I want to go, when the time comes. Quickly, comfortably, and preferably not with any tubes inserted.

In my idealised shuffle from this mortal coil, when the inevitable final deterioration is confirmed, the background music will be tasteful and uplifting, and the bystanders impeccably dressed. No half-hearted CPR from an intern in shabby jeans, thank you.

In all likelihood, however, my demise will not be in my home, but in hospital, where more and more of our elderly spend their final days. My family, buffeted by memories of  successful CPR attempts on every TV medical drama they’ve ever seen, will demand that doctors “do everything they can”.

Not like prime time.
Not like prime time.

No harm done, of course. If the outcome is the same, so be it. At least my relatives will have the ‘comfort’ of knowing that no stone was left unturned in the fight to bring me back from the brink. That’s the least any of us would wish for – or is it?

The Hinterland

What many fail to recognise is that “do everything we can” now includes replacing virtually all of the body’s essential functions. The chest rises and falls, mimicking breathing; a ‘good’ blood pressure is generated; failing kidneys are replaced… long after the real spark of life has left, or long after it’s become apparent that we’ll never again have a meaningful interaction with the person we loved, the machines continue.

Is this really comforting our relatives?

Doctors now recoil from the prospect of prolonging this life-without-life. Ask Heidi Flori, an intensive care doctor battling not to insert long-term feeding and breathing tubes into the body of a 13-year old girl already declared legally dead. She doesn’t mince her words in describing what these “comforting” measures mean in practice.

We bring the possible, you bring the patient?

Our technology can simulate the signs of life, but intensive care doctors don’t mistake a working machine for a recovering patient. Who, then, should be in intensive care in the first place?

Opening more Intensive care beds for a population just drives the wrong people into those beds. People who won’t benefit from Intensive care – either because they’re not sick enough to really require it, or because their outcome will be dreadful, regardless of what their doctors do.

So what do we do differently?

As communities, we understand that expanding intensive care units is unlikely to improve our communal health in the way we want.

As doctors, we comfort deteriorating patients – and their distraught relatives – whilst making them aware of the brutal reality of what  it means to be an intensive care patient.

As people, we talk to our families about what we really want. Perhaps we should consider an intensive care admission the exception, not the expectation.

These medical charges come at too high a price

Every doctor has ugly secrets: the diseases they can’t confidently diagnose; the colleagues they struggle to work with; the new drugs they don’t know about yet. I have another one – I’m a dreadful immigration officer.

This didn’t use to stop me going about my business on the wards. The UK government’s recent proposal that Emergency departments charge migrants for emergency medical treatment is going to make it much more difficult.

Earl Howe (Under-Secretary of State for Health, surprisingly, despite a career in banking – not healthcare) tells us we need a “system… fair to the hardworking British taxpayers who fund it”. Absolutely right. But arguments about individual immigration rights and treatment eligibility need to stay out of the Emergency department.

Anyone who says otherwise needs a medical check-up (if they’re eligible). This ill-thought out and dangerous policy is going to make life more hazardous for staff and patients – regardless of their nationality.

The proposal is unworkable, unpalatable, and it makes for bad medicine.

It’s unworkable

Our Emergency departments already struggle to see patients withoutintolerable delays. There’s absolutely no way that frontline staff can request a credit check on each new patient without it taking time away from their other work.

Ministers are confident that clinicians will somehow save them from having to make explicit what they’re actually proposing. They’re suggesting that the NHS, which spent over £12 billion failing to introduce a computerised health record, take on the roles of passport control, financial advisors and bailiffs, applying those roles fairly and transparently across different hospitals, whilst still trying to diagnose and treat our “hardworking English taxpayers” within four hours of their arrival.

Some would call this ambitious. Others would be less polite. Especially when the real immigration people aren’t doing so well.

The Department of Health says “life saving treatment” will still be provided for all, free of charge. But even if we did establish at the front desk that this was all a patient was entitled to, what does that actuallymean in practice?

It’s a wonderfully soothing term: free treatment only for the most needy. The reality is different. Most patients who need inpatient treatment aren’t critically unwell. But failing to provide timely treatment when their illness is manageable makes it more likely that when they do return, it really will be an emergency. Emergencies are more expensive to treat, but the NHS will cover them for free.

Our government is openly proposing to send home from A&E patients with treatable conditions who can’t pay up. ‘Sending them home’ means they’ll go back to their hostel in Brentford, of course, not their family doctor in Bangalore. So they’ll end up returning to the same A&E for more expensive treatment than they needed the first time round.

Then, because they’re only entitled to “life saving” care, they’ll be discharged too early, without the medication that will help them recover, to begin the cycle again. If this saves anyone money, sign me up for a Ponzi scheme.

It’s unpalatable

The sad truth about hospitals is that they don’t deal with groups of people, they deal with individual patients. And whilst it may be politically expedient to limit care for Immigrants (caricatured as populations, parasites, threats), immigrants (individuals, real people) tend to be far more deserving.

Most of the patients receiving care to which they’re not fully entitled will be confused, elderly people who need help from a system that no longer deems them eligible for it. Like this man. Whilst they may approve of healthcare restrictions in theory, hardworking British taxpayers will find it entirely unpalatable to see individual patients chased down for the crippling costs of their healthcare.

We will balk at it. We are the most charitable developed nation in the world. We will not sit comfortably when the elderly man in the Resuscitation bay opposite ours is told to leave because he’s now “well enough”, knowing that the decision would have been different if he hadn’t reached his credit limit.

It makes for bad medicine

To my eternal shame (and I truly mean that: I will never do this again), I once tried to combine the roles of doctor and immigration officer. My patient, Aziz*, had already been treated in his own country for a serious infection arising from a large tumour. He then travelled to London hoping to find a private surgeon who would treat him. Aziz’s condition worsened, and he was brought straight from the airport to my hospital.

On the ward, I faced daily dilemmas. Aziz was stable, but still required ongoing care for a recurrence of his infection. When did this stop being an emergency? Had it ever been an emergency? To what extent should I restrict my involvement with him and his family, preserving my time for the patients entitled to full NHS treatment?

Insidiously, these questions corrupted the entire ward. Doctors and nurses all collaborated with an institutional diktat to limit care to the bare minimum, to varying degrees. It affected our relationships with allof our patients, first imperceptibly and then overtly.

We were no longer the advocates for their best interests. We were the lickspittles of a system that told us to approach people for their PIN codes, not their consent. They did not thank us for defending their taxes. Everyone was poorer for the experience, migrant or not.

Too high a price

These proposals go further than ever before in placing an administrative burden on Emergency departments that will be unworkable and opaque.

It will be applied haphazardly throughout the country.

It will be more expensive than what we have now.

It will appal the public.

It will corrode the professionalism and integrity of the clinical staff who look after all of us. I’ve seen that.

It’s targeting a problem that costs us 0.06% of the NHS’ annual budget.

I’d rather not, if it’s all the same to you. If the government wants to win some cheap votes on immigration, there are one or two other places to start.

*patient details changed

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